AB0395 DE-ESCALATION OF DMARDs IN ELDERLY PATIENTS WITH RA
Authors: L. Robson, F. Hayes
Journal: Annals of the Rheumatic Diseases (2022)

Background Rheumatoid Arthritis is the most common form of inflammatory arthritis in older adults, with the mainstay of treatment being the conventional DMARDs (Tutuncu &amp; Kavanaugh, 2007). These drugs are not without side effects, and as elderly people have higher rates of adverse drug reactions and less long-term benefits, the risk/benefit ratio is different compared to other age groups. This research sought to evaluate if the rheumatology department at Southend hospital was sufficiently acknowledging the changing circumstances of their elderly patients and de-escalating conventional DMARDs accordingly. As the average age of rheumatology patients is only likely to increase in the future, contextualising a patients treatment plan for their rheumatological disorder with their overall health status will become an increasingly important skill for clinicians and the observations from this study will be applicable to all who treat elderly patients with inflammatory disorders. Objectives 1. Evaluate if major new diagnoses were acknowledged in the rheumatology clinic and if conventional DMARD treatment was reduced in response. 2. Record and compare the outcomes of when conventional DMARD was stopped abruptly vs when it was tapered down slowly. Methods Evaluated 10 year’s worth of clinic letters from rheumatology and other specialities in 50 patients with a diagnosis of RA over the age of 89. Noted new diagnoses of dementia, cancer and frailty (multiple falls, care home admission or becoming newly house bound) as well as acute hospital admissions and declining renal function and evaluated if this was acknowledged in clinic letters and whether treatment was changed in response. Recorded all instances where conventional DMARDs were stopped or had a dose reduction and evaluated if these dose drops were successful (patient stayed at reduced dose with no flares in disease activity), semi-successful (patient had mild RA flare treated with short course corticosteroids, or stayed at reduced dose for at least a year before returning to original dose) or unsuccessful (patient suffered flare and went back to original dose within 1 year.) Results Of the 50 patients, 31 received methotrexate monotherapy, 12 methotrexate and other conventional DMARDs, and 5 DMARDs other than methotrexate. 36 out of 45 patients receiving methotrexate had some decrease in dose by the end of the 10 year period, with the median decrease being 5mg. Patients on multiple DMARDs saw a greater average decrease in methotrexate compared to those on monotherapy. 15 abrupt cessations in methotrexate were recorded, with acute hospital admission being the most common trigger. Of these 3 were successful, 5 were semi-successful and 7 were unsuccessful. 55 planned methotrexate dose reductions in the rheumatology clinic were recorded, with 38 being successful, 9 being semi-successful and 8 being unsuccessful (Figure 1.). Clinic letters did generally acknowledge both new physical diagnoses and changes in social circumstances, but some diagnoses were more likely to trigger a change in treatment, for example in 8 new cancer diagnoses, there were 5 changes to treatment, whereas in 12 dementia diagnoses there were 3 changes to treatment. 6 patients received more methotrexate than guidelines suggest for their level of CKD, with 3 of these having it acknowledged in clinic letters. Conclusion Most patients had a reduction in dose of methotrexate over a 10 year period. Planned de-escalations were mostly successful, whereas abrupt stops to treatment were generally less successful. Rheumatologists are good at acknowledging changes to health status but were more likely to change DMARD therapy in response to a cancer diagnosis than a dementia diagnosis or frailty. There is still some work to be done in acknowledging declining renal function and changing methotrexate in response. Overall, these results suggest de-escalation is mostly successful and clinicians can be confident in further expanding this into their day to day practice. References [1]Tutuncu, Z. and Kavanaugh, A., 2007. Treatment of elderly rheumatoid arthritis. Future Rheumatology , 2(3), pp.313-319. Acknowledgements Many thanks to my supervisor Dr Fiona Hayes and the rest of the rheumatology team at Southend University Hospital for being so welcoming and allowing me to make full use of the tea supplies. Disclosure of Interests None declared